H pylori eradication in everyone?

The Maastricht/Florence consensus does not contain any comprehensive list of indications for Helicobacter pylori testing, unlike the recent American College of Gastroenterology guidelines. In the light of the somewhat obscure statement saying that “H pylori gastritis is an infectious disease irrespective of symptoms and complications,” should we attempt to diagnose and eradicate H pylori only in patients with suspected infection (eg, those with a history of exposure to persons with confirmed infection), or rather in everyone?

Paul Moayyedi: It is an interesting question, and I do not think there is an easy answer to that. I think the Maastricht approach, whilst I was part of that Maastricht committee, is not something I agree with. I do not think you can say it is an infectious disease because in most people it does not cause problems. Just from a philosophical point of view, I feel that that is not the correct approach but I accept that there will be differing opinions, and it is more philosophical than anything else.

I do not adhere to it being an infectious disease per se, but I do believe a significant minority of the population will develop problems. The most concerning pathology is gastric cancer. I do believe in high prevalence of gastric cancer, or [countries with] high incidence of gastric cancer—those countries, if they can afford it, should consider screening populations and treating whole populations to reduce the risk of gastric cancer. There is now reasonable randomized trial evidence that that will reduce the incidence of gastric cancer, and I think in places like Japan and China, as they get richer, they should consider that approach; South Korea is another example.

In lower-risk countries, which is most of Europe and North America, it is less clear that that is a sensible strategy, although our work would suggest even there it could be cost-effective as it reduces peptic ulcer disease and dyspepsia in the community and the attendant costs of that. Even in low-risk countries you could consider it, but I certainly would not push for that to happen.

The only other time you should eradicate H pylori is if it is in the presence of dyspepsia, where a small number will be improved, peptic ulcer disease, and of course rare things like mucosa-associated lymphoid tissue (MALT) lymphoma.